This invention teaches a system to enable a professional medical provider to set up and maintain billing rules and parameters used for patient charging for surgical procedures, and for generating patient charges in batch mode, where said charges may be reviewed and modified by personnel of the provider before being sent to the provider's billing system. It will be noted that the system of this invention is limited to billing charges for surgical procedures, including pre-op, the operating room procedures, i.e. operation, and post-op, and that ancillary charges related to a patient's stay at such facility, such as room, telephone, medication, and rehabilitation, are not included in this system.
Professional medical providers today seem to be spending an inordinate amount of time in generating paper work regarding patient charges before sending same to the patient and/or insurance provider. The time spent is nonproductive insofar as providing direct and needed services to a patient, and adds significantly to the overhead of the medical provider. There is the additional burden of being accurate and complete in defining the resources, i.e. procedures, materials, or other defined resources, that can be quantified for billing the patient and/or insurance provider.
In the age of third party payments, it is essential for billing purposes that the appropriate level of service be recorded for each patient-provider encounter. If the level of service recorded is higher than the level of service actually performed, the provider may be subject to liability for over charging. On the other hand, if the level of service recorded is lower than actually performed, the provider may not capture complete revenues for the service provided. Because the potential liability for over billing is so high, providers may routinely tend to record the level of an encounter lower than warranted by services actually delivered so as to forestall a charge of over billing. There is therefore a need for accurately determining and recording the appropriate level of encounter when a provider renders services. In addition to assigning accurately a level of service, and the resources used in providing such service, it is also important for a provider to record accurately and promptly procedures performed on a patient and the diagnosis or diagnoses which prompted the patient encounter.
In an effort to provide a complete, accurate and fair accounting of patient charges for medical procedures, the prior art has developed several systems to ensure such procedures are accurately reported and reflected in the charges sent to the medical provider. Examples of such prior art systems are described in the following U.S. Patents:
a.) U.S. Pat. No. 5,970,463, to Cave et al., relates to a medical claims integration and data analysis system that categorizes medical claims into episodes of care having predetermined diagnostic cluster types. The system analyzes medical claim items, some of which have principal diagnosis codes, and some of which have non-principal, missing, or incorrect diagnosis codes. Patient treatment episodes (PTEs) are formed from the principal diagnosis codes, each PTE being of a particular diagnostic cluster type. The system categorizes non-principal-diagnosis claim items into the PTEs on the basis of temporal, physiological or clinical relationships between the claim items and the PTEs. A drug lookup table enables drug claims to be properly categorized in the PTEs. A diagnostic cluster lookup table enables claim items to be categorized into PTEs with ongoing treatment windows for which the diagnosis code of the claim item is in the diagnostic cluster lookup table. The system merges PTEs of the same diagnostic cluster type when the treatment windows of the PTEs overlap. The system attempts to recategorize medical claims into merged PTEs. The system analyzes each PTE to determine the presence of required diagnosis and eliminates any PTE without a required diagnosis. The system also identifies and merges PTEs that are clinically related or clinically similar. In a system for integrating medical claims data, medical claim items that are in different data formats and/or use different coding systems are analyzed, and related claim items are categorized in a common coding system.
b.) U.S. Pat. No. 5,933,809, to Hunt et al., teaches a computer software system for processing medical billing record information that is capable of being executed by a conventional computer microprocessor to perform information processing on pre-existing medical billing record information, preferably consisting of hospital or individual doctor Medicare billing records. The software contains at least one set of instructions for receiving, converting, sorting and storing input information from the pre-existing medical billing records into a form suitable for processing. The software contains at least one set of instructions for processing the input medical billing record information, preferably to identify potential Medicare “72 hour billing rule” violations. This processing is preferably performed by comparing each input medical billing record containing dates of medical inpatient admission and discharge to each input medical billing record containing a date of medical outpatient service. The inpatient and outpatient billing records are first compared to determine if they contain matching patient identification codes to identify all the record originating from the same patient. If matching patient identification codes are found, the inpatient and outpatient billing records are further compared to determine if the date of outpatient service fell within a preselected time period, preferably 72 hours, prior to the date of inpatient admission. If so, the matching inpatient and outpatient billing records are distinguished and stored separately for further processing. If not, the matching inpatient and outpatient billing records are compared to determine if the date of outpatient service fell between the inpatient admission and discharge dates. If this is the case, the matching inpatient and outpatient billing records are again distinguished and stored separately for further processing. If not, the program proceeds to the next set of billing records to repeat the sequence.
c.) U.S. Pat. No. 5,229,584, to Erickson, is directed to a medical billing system that includes bar code reading apparatus which communicates with a hand held computer. The computer includes an encounter, diagnosis and procedure data base stored in memory. Bar coded procedure and diagnosis information readable by the bar code reader is provided. The computer is programmed to determine a level of service from the encounter information selected by the healthcare provider. The system provides an accurate way of assessing the appropriate level of encounter and it provides a compact, rapid method of collecting all data necessary to generate an accurate bill resulting from an encounter between a patient and a healthcare provider.
While the prior art, as exemplified in the above U.S. Patents present a billing system for use by medical facilities, none offer the support and need in providing an effective and accurate system for billing charges for surgical procedures in the manner of the present invention. The manner by which this invention achieves the desired goals hereof will become more apparent in the description which follows, particularly when read in conjunction with the accompanying schematic flow diagrams.